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Unit 1 Clin Med III > L2: GERD, esophageal disorders/cancer > Flashcards

L2: GERD, esophageal disorders/cancer Flashcards

1
Q

Red flags that require workup as they are not likely to be GERD

A 
Dysphagia→ may represent a complication, may be normal GERD
Hematemesis/GI bleeding
Weight loss, fever, fatigue
Anemia
*Inadequate response to tx*
Prior anti-reflux surgery
Personal history of cancer
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2
Q

GERD definition

A

Lower esophageal sphincter transiently relaxes→ backflow of stomach contents

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3
Q

Montreal classification of GERD

A

reflux of stomach contents cause troublesome symptoms or complication

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4
Q

Symptoms of GERD

A 
Postprandial Heartburn (pyrosis)
Regurgitation
Bronchospasm
Laryngitis/hoarseness (consider laryngoscopy)
Chronic cough
Loss of dental enamel
Chest pain→ squeezing, substernal, radiate to back, neck, jaws, arms→ RULE out cardiac cause
Dysphagia→ rule out stricture
Water brash/hypersalivation
Globus sensation (lump in throat)
Odynophagea
Nausea
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5
Q

Hallmark symptom of GERD

A

Postprandial Heartburn

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6
Q

How is GERD diagnosed?

A

CLINICALLY

Testing not usually needed

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7
Q

Things that may aggravate GERD

A 
Obesity
Gravity→ elevate head of bed
Pregnancy
Tobacco/ETOH→ lower esophageal sphincter pressure
Foods
Meds that decrease LES pressure
Anticholinergics (Ditropan)
TCAs (Amitriptyline)
CCBs
Nitrates
Narcotics
Meds that injure mucosa: 
*Bisphosphanates* (fosamax, actonel)
Iron supplements
NSAIDs/ASA
Potassium
Tetracycline
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8
Q

Amitriptyline

A

TCA

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9
Q

Ditropan

A

Anticholinergic

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10
Q

Fosamax, actonel

A

Bisphosphonates

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11
Q

Best diagnostic study to evaluate mucosal injury

A

EGD

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12
Q

Esophageal impedance testing

A

Shows complete vs incomplete bolus transit

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13
Q

Esophageal pH monitoring

A

Transnasal catheter vs wireless capsule option

Quantify reflux, pt logs symptoms. High sensitivity

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14
Q

Esophageal manometry

A

Measures function of LES and peristalsis, pressures and patterns of esophageal muscle contraction

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15
Q

2 types of hiatal hernias

A
  1. Sliding hernia (most common)

2. Paraesophageal hernia (may require surgery)

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16
Q

A hiatal hernia is when….

A

a portion of the stomach enters above the diaphragm into the chest

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17
Q

How are hiatal hernias usually diagnosed?

A

Asymptomatic, usually incidental finding on a CXR:
retrocardiac mass +/- air fluid level
Without air fluid level, hard to diagnosis from CXR alone

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18
Q

Hiatal hernias have an increased risk of…

A

Mallory Weirss Tear

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19
Q

Hiatal hernias presentation

A

GERD: heartburn, cough, hoarseness, chest pain

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20
Q

Hiatal hernias treatment

A

Treat similarly to GERD

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21
Q

Lifestyles modifications to treat GERD

A 
Adjust bed to raise head
No food/drink within 3 hours of bedtime
Weight loss
Eliminate dietary triggers→ +/- chocolate, fried/fatty, caffeine, soda, alcohol, peppermint, citrus, onions, tomatoes
Eat smaller meals
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22
Q

Mild/intermittent GERD tx approach

A

Step up therapy
Less than 1-2 episodes/week + no evidence of erosive esophagitis
Tx: lifestyle modifications, H2RAs +/- Antacids

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23
Q

Severe GERD tx approach

A

Step down therapy
Frequent, >1-2 episodes/week, impair quality of life
Tx: PPI daily x 8 weeks + lifestyle modifications → gradually decrease therapy

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24
Q

Antacids (TUMS)

A

Neutralize gastric pH, short lived benefit, do not prevent GERD

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25
Q

Ranitidine

A

H2 blocker

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26
Q

H2 blockers MOA

A

Block action of histamine at H2 receptors of gastric parietal cells→ decreased secretion of acid

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27
Q

1st line medication for GERD

A

H2 blockers low dose PRN

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28
Q

If a patient is taking the maximum dose, BID, of a H2 blocker and is still refractory…

A

Switch to PPIs

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29
Q

Omeprazole (Prilosec)

A

Proton Pump Inhibitor

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30
Q

Lansoprazole (Prevacid)

A

Proton Pump Inhibitor

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31
Q

Esomeprazole (Nexium)

A

Proton Pump Inhibitor

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32
Q

Pantoprazole (Protonix)

A

Proton Pump Inhibitor

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33
Q

PPIs MOA

A

Reduce amount of acid produced by glands in the stomach

Take 30 minutes before the 1st meal of the day

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34
Q

How to dose a PPI

A

Without barrett’s take the lowest dose for the shortest possible duration
discontinue in patients without symptoms

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35
Q

If a low dose PPI is not effective

A

increase from once daily to BID
follow up or schedule endoscopy
If warning signs, endoscopy indicated

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36
Q

PPI dosing for Barrett’s esophagus

A

longer term use

maintenance acid suppression to avoid recurrence of symptoms

37
Q

PPIs adverse effects

A 
Risk of infection
Decreased acid→ decreased protection against bacteria→ C. Diff, other infections
Malabsorption
*Magnesium*, +/- Calcium, B12,  Iron
Other risks → dementia, heart disease?
38
Q

Monitor _______ while on PPIs

A

Check Mg periodically +/- yearly B12, bone density

39
Q

Indications for anti-reflux surgery

A

Failed optimal medical management
GERD complications→ esophagitis, Barrett’s
Noncompliance

40
Q

Nissen Fundoplication

A

Preferred anti-reflux surgery
laparoscopic or open
Passage of gastric fundus behind to esophagus→ encircle distal esophagus

41
Q

Esophagitis definition

A

Gastric acid + pepsin + bile → irritation of the squamous epithelium→ inflammation, irritation, erosion, ulceration

42
Q

Types of esophagitis

A 
Reflux (most common)
Infectious
Pill
Eosinophilic
Radiation
43
Q

Esophagitis presentation

A

Similar to GERD→ heartburn, regurgitation, cough, chest pain

44
Q

Complications of esophagitis

A

Bleeding
Stricture
Barrett’s Esophagus

45
Q

Barrett’s esophagus

A

Recurrent acid injury→ squamous epithelium in distal esophagus replaced with columnar epithelium

46
Q

Barrett’s: _____ epithelium in _____ esophagus are replaced with _____ epithelium

A

squamous
distal
columnar

47
Q

Progression of Barrett’s esophagus

A

GERD→ Barrett’s Esophagus→ low grade dysplasia→ high grade dysplasia→ Adenocarcinoma

48
Q

Who get Barrett’s esophagus

A

M>F, 55 years

Found in 10-15% of patients undergoing EGD for GERD

49
Q

Treatment of Barrett’s esophagus

A

PPI→ indefinite use
EGD surveillance→ detect evidence of dysplasia
Removal

50
Q

2 ways to remove cells of Barrett’s esophagus

A

Endoscopic Eradication Therapy (EET)/Endoscopic Ablation (EA)

Thermal or photochemical energy to destroy Barrett mucosa

Endoscopic Resection (ER) 
Remove segment of Barrett mucosa→ therapeutic and quantifies depth of involvement
51
Q

2 types of esophageal cancer

A

Squamous cell carcinoma

Adenocarcinoma

52
Q

Squamous cell carcinoma vs Adenocarcinoma: Epidemiology

A

Squamous cell carcinoma: urban areas, african american men

Adenocarcinoma: caucasians, M>F

53
Q

Squamous cell carcinoma vs Adenocarcinoma: incidence

A

Squamous cell carcinoma: decreasing

Adenocarcinoma: increasing, focus on early detection and prevention

54
Q

Squamous cell carcinoma vs Adenocarcinoma: risk factors

A

Squamous cell carcinoma: smoking, alcohol, diet low in fruits/vegetables, selenium/zinc deficiency, caustic esophageal injury, +/- HPV

Adenocarcinoma: Barrett’s → .5%/ year (1/200) progress
Smoking, obesity

55
Q

Presentation of esophageal cancer

A

Progressive dysphagia:
solid food→ soft foods→ liquids
Weight loss, odynophagia, malnutrition, anorexia

56
Q

Esophageal cancer prognosis

A

50-80% of patients present with incurable, unresectable, or metastatic disease→ palliative treatment:
+/- Chemo, radiation, surgery

57
Q

If a patient has dysphagia…

A

perform endoscopy!

+/- Barium contrast esophagram

58
Q

Infectious Esophagitis

A

Immunocompromised, inhaled steroids, recent abx use→ Candida

59
Q

Tuberculosis Infectious Esophagitis

A

Night sweats, cough, (+) PPD

60
Q

Pill Esophagitis

A

Medication induced, ibuprofen “gets stuck”

61
Q

Esophagitis Associated with Systemic Illness

A

Systemic Sclerosis (collagen vascular disease) → poor acid clearing→ Epithelial damage

62
Q

Eosinophilic esophagitis definition

A

Asthma, rhinitis, food allergies, chronic eczema (atopic dermatitis)→
Chronic, immune/antigen-mediated, eosinophil predominant inflammation
Incidence increasing, M>F

63
Q

Eosinophilic esophagitis symptoms

A 
Dysphagia
food impaction
chest pain
refractory heartburn/GERD
upper abdominal pain
64
Q

Eosinophilic esophagitis diagnosis

A

clinical history + EGD→ stacked circular rings, stricture

65
Q

Eosinophilic esophagitis treatment

A

Diet→ avoid allergens
PPI
Topical corticosteroids→ ICS spray + swallow (don’t inhale)
+/- esophageal dilation

66
Q

Stacked circular rings and stricture on EGD

A

Eosinophilic esophagitis

67
Q

Symptoms of esophageal motility disorders

A

Dysphagia
non-cardiac chest pain
refractory GERD

68
Q

How to diagnose esophageal motility disorders

A

Must first perform EGD→ rule out structural abnormality
Manometry
barium swallow
esophageal pH impedance monitoring

69
Q

Hypercontractile/Jackhammer Esophagus presentation

A

angina that occurs with meals

70
Q

Hypercontractile/Jackhammer Esophagus on manaomatry

A

high pressure (high amplitude) contraction in the esophagus with normal relaxation of the esophagogastric junction

71
Q

Hypercontractile/Jackhammer Esophagus treatment

A

CCB (diltiazem) or TCA (imipramine)

+/- botulinum toxin injection

72
Q

Diltiazem

A

CCB

73
Q

Imipramine

A

TCA

74
Q

Achalasia definition

A

progressive degeneration of esophageal neurons→ failure of relaxation of lower esophageal sphincter and lack of peristalsis

75
Q

Achalasia presentation

A 
gradual onset, rare
dysphagia
regurgitation
difficulty belching
chest pain
heartburn
76
Q

In which patients should you consider Achalasia?

A

a patient who is unresponsive to PPIs after 4 weeks with dysphagia to solids and liquids with regurgitation

77
Q

Diagnosis of Achalasia

A

EGD→ required to rule out malignancy
Manometry→ Required for diagnosis
Barium esophagram

78
Q

Achalasia on manomety

A

Aperistalsis (no contraction) in distal 2/3rds of esophagus and incomplete lower esophageal sphincter relaxation
Required for diagnosis

79
Q

Achalasia on barium esophagram

A

Esophageal dilation
Birds Beak sign
Aperistalsis
Poor emptying of barium

80
Q

Treatment of achalasia in a low surgical risk patient

A

Myotomy or Pneumatic Dilation

If it fails, repeat or try the other

81
Q

Treatment of achalasia in a high surgical risk patient

A

1st line Botulinum toxin

2nd line Nitrates, CCBs

82
Q

Heller myotomy

A

incision that disrupts lower esophageal muscle fibers to treat achalasia

83
Q

Pneumatic dilation

A

disrupts lower esophageal muscle fibers to treat achalasia

Sized 3 cm to 4 cm

84
Q

Biochemical reductions in Lower Esophageal Pressure (3)

A

Botulinum toxin
Nitrates
CCB

85
Q

mucosal laceration in distal esophagus and proximal stomach

A

Mallory Weiss tear

86
Q

Mallory Weiss tear presentation

A

repetitive vomiting and retching, hematemesis

87
Q

Predisposing factors of a Mallory Weiss tear

A 
excessive ETOH intake
hiatal hernia (increased abdominal pressure)
88
Q

Mallory Weiss tear diagnosis

A

Endoscopy

If already resolved, clinical diagnosis

89
Q

Mallory Weiss tear treatment

A

Stabilize patient
Control bleeding→ epinephrine or electrocoagulation
PPI
Address predisposing factors

Unit 1 Clin Med III (7 decks)

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